2017 Range Regulation Appendices 21JAN17. Appendix D CRTC ACCIDENT AND INCIDENT REPORTING FORMS

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1 Appendix D CRTC ACCIDENT AND INCIDENT REPORTING FORMS

2 CRTC ACCIDENT/INCIDENT REPORT (Items derived from DA Form 285-AB-R) 1. DTG OF ACCIDENT/INCIDENT (1): 2. UNIT (5): 3. LOCATION OF ACCIDENT/INCIDENT (6): 4. MISSION (BRIEF DESCRIPTION) (8): 5. INDIVIDUAL(S) INVOLVED (11): NAME (LAST, FIRST, MI) SOCIAL SEC. # GRADE SEX AGE 6. WERE PERSONNEL HOSPITALIZED? (21) YES / NO (CIRCLE ONE) 7. DESCRIBE ACCIDENT/INCIDENT (24): 8. WAS ACCIDENT/INCIDENT CAUSED BY (CIRCLE ALL THAT APPLY) (37): LEADER TRAINING STANDARDS/PROCEDURES SUPPORT INDIVIDUAL DESCRIBE: 9. CORRECTIVE ACTIONS TAKEN OR PLANNED (40): 10. POC FOR INFORMATION ON ACCIDENT/INCIDENT (41): (INCLUDE NAME, RANK, POSITION, UNIT, HOR, AND PHONE NUMBERS) 11. HAS AN ATS FORM 47A BEEN COMPLETED, IF THE INDIVIDUAL WAS TREATED AT AN OFF-POST MEDICAL FACILITY? YES / NO / NA 12. WAS A COPY LEFT AT THE MEDICAL FACILITY, CAMP RIPLEY MUTF (TMC), AND RANGE CONTROL? YES / NO / NA (NUMBERS IN PARENTHESES ARE THE LINE ITEM NUMBERS OF DA FORM 285-AB-R)

3 RANGE ACCIDENT/INCIDENT CHECKLIST Vehicle / Barrier / Training Area DATE 1. Notify Range Control: SINCGARS /40.400, Motorola radio, or Telephone or Report the nature of accident/incident and have information available. Vehicle Accident/Incident Date and time of incident: Type of accident/incident: Personnel injured: Yes No Vehicle damage: Yes No Grid: Activity being conducted: Name of individual and unit reporting: Barrier breach Barrier # or Grid: Damaged: Yes No Date and time of incident: Duration in area: Number and type of vehicles involved: Number of personnel involved: Name and unit of individual in charge: Damage to Training Area or property Damage was caused by: Tracked Vehicle Wheeled Vehicle Troop use Fire Other Training Area # and Grid Approximate amount of damage: Engineer equipment required: YES NO TYPE: Personnel reporting and Unit: 3. Stand by for instructions from Range Control. 4. If Accident/Incident warrants investigation, Range Control may request unit to submit an AGAR Form 285-AB-R.

4 RANGE INCIDENT CHECKLIST Indirect Fire 1. Immediately place the firing point in Cease Fire Freeze status. 2. All personnel will fall away from weapons without changing settings. 3. Notify Range Control on SINCGARS / immediately and give the following information: Name of unit Grid location of weapon round was fired from Type and size of round Azimuth, Elevation, and Charge Round was: Out of Safe Unobserved Name and Rank of person reporting incident 4. OIC investigates to determine: Personnel injured Equipment Damage General direction (out of limit) that weapon was fired Number of rounds fired Personnel were forward of established firing position Number of personnel forward of firing position Reason forward of position 5. Stand by for instructions from the Range Control. 6. If accident/incident warrants investigation, Range Control may request unit to submit ATS Form 285-AB-R (Accident/Incident Report). 7. Firing will be resumed upon approval from Range Control.

5 RANGE INCIDENT CHECKLIST Direct Fire 1. Immediately place the firing point in Cease Fire Freeze status. 2. All personnel will fall away from weapons without changing settings. 3. Notify Range Control: SINCGARS , Motorola radio, or Telephone or cell phone : Range Designation: Name of unit: Name and rank of person reporting incident: Type of incident: OIC investigation results: 4. OIC investigates to determine: Personnel injured Equipment Damage General direction (out of limit) that weapon was fired Number of rounds fired Personnel were forward of established firing position Number of personnel forward of firing position Reason forward of position 5. Stand by for instructions from Range Control. 6. If accident/incident warrants investigation, Range Control may request unit to submit ATS Form 285-AB-R (Accident/Incident Report). 7. Firing will resume upon approval from Range Control.